An Operation Rescue Commentary By Cheryl Sullenger
Karnamaya Mongar, a tiny Bhutanese refugee who barely spoke a word of English, never meant it to happen, but her death at the hands of Kermit Gosnell and his incompetent staff on November 19, 2009, has served as an object lesson in the dangers of assumptions.
Mongar had newly immigrated to the U.S. with her family, who was struggling to make ends meet on low-wage jobs in Virginia. When she discovered she was pregnant, she did not realize that there were resources available in her community to help her. She assumed abortion was the only solution.
Because of her advanced pregnancy, Mongar was referred by another abortion business to the Women’s Medical Society in West Philadelphia, Pennsylvania. She assumed that Gosnell and the other workers at the Women’s Medical Society were good care givers who provided competent care to their patients.
Her assumption proved fatal.
Amid the squalor that characterized Gosnell’s cluttered, ramshackle abortion facility, Mongar was overdosed by unsupervised, uneducated, and untrained workers. When her heartbeat stopped as she lay on the torn and rusty procedure table, Gosnell was incapable of resuscitating her. After paramedics were finally called, they arrived to find Mongar still on that filthy table with her legs in the stirrups. No one was attending her. Gosnell had moved on to other patients.
Dr. Gary Collins worked in the Philadelphia Medical Examiner’s office and received Mongar’s body for autopsy. He discovered that she had been overdosed with Demerol – a cheap drug that had fallen out of favor with all but abortionists due to its dangerous side effects.
Collins assumed that the Women’s Medical Society was a legitimate medical practice that adhered to patient care standards and that Gosnell was a competent physician who had done all he could for Mongar.
Nevertheless, Collins took nine months to conclude that Mongar’s death was the result of “accidental overdose” and noted as much on her death certificate on August 13, 2010.
However, once the Grand Jury began to investigate, they provided Collins with additional information about conditions and practices at what has become known as Gosnell’s “House of Horrors.” Stunned by what he learned, he changed the cause of death to “homicide” on December 17, 2010.
At Gosnell’s trial, which I attended in the spring of 2013, Collins explained to the jury about the change to Mongar’s manner of death.
“From the get go, the circumstances (described) were inaccurate — totally inaccurate. That made it sound like everything was being done above board,” Collins testified.
He was shocked to learn of the wretched conditions and substandard practices that Gosnell and his incompetent staff inflicted upon vulnerable women. The gross negligence involved qualified Mongar’s death as a “homicide,” for which Gosnell was later convicted of Involuntary Manslaughter, along with hundreds of other crimes, including the first-degree murder of three babies that had been born alive.
Collin’s initial mishandling of Mongar’s autopsy has been commonly replicated among other coroners who have recently handled abortion death cases. Autopsy reports take months longer to release than 6-8 weeks, which is standard for non-abortion related cases. Medical Examiners assume that the abortion facility followed standards in patient care and facility sanitation. They assume that the abortionist is a competent physician that did all he could for the patient. They assume anything the abortion provider tells them is true.
But all of those assumptions are wrong.
Here is a new thought for medical examiners around the country: Abortion facilities are not legitimate health care centers, and should not be treated as such.
Abortion facilities adhere to much lower standards, because it is more profitable for them to do so. It is cheaper to hire untrained workers, to order the cheapest drugs, and cut corners on the tedious process of sterilizing surgical instruments, as Operation Rescue has repeatedly documented through gag-inducing Health Department inspection reports from abortion facilities all over the nation.
They are in business to sell abortions and make money in a market where there is a declining demand for their services. They are financially rewarded for cutting corners women’s health. They are protected by politics that encourage regulators to look the other way when problems arise, slap offenders on the wrist when they are caught, and keep abortion facilities open no matter who suffers.
In Pennsylvania, such a political climate allowed – no, encouraged – Kermit Gosnell’s appalling practice to thrive.

In a recent abortion-related death case, Medical Examiner Dr. Elizabeth A. Douglas most likely never visited the Kalamazoo Planned Parenthood facility where Cree Erwin-Sheppard received her fatal abortion in 2016. There is no indication that Douglas asked the hard questions about why a supposedly “safe” first-trimester surgical abortion went so wrong and who was responsible for this young mother’s death. In fact, Douglas went to a great deal of trouble to excise any mention of Planned Parenthood or abortion from Erwin-Shepard’s autopsy report. After over eight months of delay, the report was released and the case closed. A “no-comment” policy was initiated for all media inquiries.
Sadly, those responsible for the death of Cree Erwin-Sheppard may never be held accountable.
Similar stories could be told about other women who perished from shoddy abortions.

Tonya Reaves died in 2012 from a uterine perforation that caused her to slowly bleed to death internally for over five hours while the Chicago Planned Parenthood abortionist delayed calling for emergency help. What was Reaves manner of death? Accident.
Case closed.
In 2013, Jennifer Morbelli received an abortion at 33 weeks into her pregnancy at Germantown Reproductive Health Services, after which her abortionist, LeRoy Carhart, got on a plane and left the state. When her already-poor condition dangerously deteriorated throughout the night, Morbelli’s family tried desperately to reach Carhart and his staff, but no one picked up the phone. By the time her family made the decision to take her to a nearby emergency room, it was too late.
Despite a clear case of patient abandonment and the release of a third-trimester surgical abortion patient before she was stabilized, (remember, Carhart had a plane to catch), the medical examiner listed her manner of death as “accidental.” The media that had showed a modicum of interest in covering Morbelli’s death assumed that “accidental” meant that it was no one’s fault.
Another case closed.
Lakisha Wilson received a fatal second-trimester abortion at Preterm, an abortion facility in Cleveland, Ohio, in 2014. Due to blood loss, Wilson suffered cardiopulmonary failure, but no one immediately noticed because she was not monitored properly. Thirty minutes later, paramedics arrived, but could not reach her due to a malfunctioning elevator. When they finally got to the second-floor abortion rooms, they could not intubate Wilson to restore oxygen flow because the elevator, which had begun to work again, was too small to lay a gurney flat as required for intubation. Wilson was pronounced dead at the hospital from brain damage due to oxygen deprivation during a heart attack she suffered immediately after her abortion.
Wilson’s manner of death? Accident. Nothing to see here. Move along.
Collins learned the hard way that when dealing with abortion-related deaths, coroners cannot assume that all is as it seems or as it might be expected. They all need to look harder at these maternal abortion deaths while laying aside the distorting lens of abortion politics.
They need to investigate as if the woman on the cold autopsy table was their own loved one, because someday, it might be.
Abortionists are not like other physicians and abortion facilities are not like other medical offices. They are worse. Much worse. And they have no moral compunctions about using deception to hide that fact, as I personally witnessed during the Gosnell trial. Until coroners and regulators learn this, those who are killing one woman after another at abortion facilities across our nation will continue to get away with it, and when they do, it is only a matter of time before they kill again.